What is “trauma”? The word seems to be used inconsistently in the mental health field, sometimes referring to an adverse event and sometimes describing the psychological injury sustained from experiencing such an event. “Trauma” comes from the Greek word for “wound, hurt, or defeat”; before 1700 it was used to mean a physical injury, the sense in which many medical practitioners today use the word. The sense of a “psychic wound, [an] unpleasant experience which causes abnormal stress” has been in use from around 1900 (Harper, 2015) and is more aligned with the counselling and psychology sense. In this article, we will refer to trauma not as an event, but as the psychological injury which results from experience of the adverse event.

Potentially traumatic events and traumatic events

Events that most of us would regard as adverse, possibly catastrophic, incidents, we will describe as “potentially traumatic events”, or “PTEs”, and once such an event has caused psychological injury, we will refer to it as a “traumatic event”. PTEs include any threat, actual or perceived, to the life or physical safety of the individual, their loved ones, or those around them. A list of potentially traumatic events would thus include, but not be limited to: war, torture, sexual assault, physical assault, natural disasters, accidents, and terrorism. Someone can experience a PTE directly (that is, the person actually experienced or witnessed it) or indirectly (learning about the event from someone else). It is to be noted, however, that the DSM-5 has excluded as traumatic events those incidents witnessed indirectly via electronic media, television, movies, or pictures, unless observing such is part of the person’s job (Australian Centre for Posttraumatic Mental Health (2013a).

PTEs can be single-occasion incidents, like the terrorist act of 9/11 (bringing down New York’s Twin Towers and killing nearly 3000 people) or the Queensland floods of early 2011, which caused death and widespread destruction of property. PTEs can also be repeated acts, such as the typical pattern of childhood sexual abuse or domestic violence. Some research has claimed that natural disasters and accidents engender less severe trauma than, say, evil acts perpetrated by human beings on others, as in terrorism, torture, or assault. Too, repeated or prolonged acts, such as with domestic violence or brutal captivity (think concentration camp experience), are more likely to result in trauma (van der Kolk, Pelcovitz, Roth, Mandel, et al, 1996). And the traumatic response does not always stop with those who have experienced it, as the potential for transgenerational effects of trauma stemming from systematic torture, genocide, family violence, or the like may occur with mental health problems in the next generation (Purdie, Dudgeon, & Walker, 2010).

Normal responses, traumatic stress syndromes, and co-morbid mental health conditions

What if you come back to a fire-ravaged area only to see your precious home in ashes? What about if you barely survive a tragedy at sea which claims hundreds of lives? Or escape from a kidnapping? It is only natural to experience some psychological distress in the aftermath of such horrific potential traumatic events. Feeling emotionally upset, increased anxiety, sleep and appetite disturbance, fear, guilt, sadness, or anger in the several weeks following events like these would be a normal response. A majority of people will find that their symptoms of psychological distress settle down in the days and weeks following such adverse incidents. Such people will use their inbuilt coping skills and, hopefully, their social support networks, to get through and prevail over the adversity with little lasting psychological harm.

However, in a minority of people, the symptoms do not settle down. Such individuals find that their stress responses following a traumatic event are severe enough to interfere with important areas of their psychosocial functioning. At this stage, an assessment for ASD and/or PTSD should be considered.

A note on co-morbidity

Before we discuss the specifics of ASD and PTSD, let us note that an Australian study of co-morbidity found that an estimated 88 percent of people with PTSD had at least one other disorder, the most common being alcohol abuse (52 percent) and depression (48 percent) (Creamer, Burgess, & McFarlane, 2001). Similarly, a large study of traumatic injury survivors found that, while nearly a third had a psychiatric diagnosis at 12 months post-injury, more than two-thirds of those did not have a diagnosis of PTSD (Bryant, O’Donnell, Creamer, McFarlane, Clark, & Silove (2010). Therefore, the picture of trauma is a complex one and co-morbidity is common.

Acute Stress Disorder

After someone has been exposed to a traumatic event, he or she may experience significant distress and/or impairment in social, occupational, or other important areas of functioning. When this lasts longer than two days, a diagnosis of acute stress disorder may be considered.

Like the DSM-IV-TR, the DSM-5 (released in 2013) requires criteria from several categories to be met before a diagnosis of ASD can be made. Criteria A involve exposure to the PTE through either experiencing it, witnessing it, learning that the traumatic event(s) occurred to a close family member or friend, or experiencing repeated or extreme exposure to aversive aspects of the traumatic event (such as first responders do). The DSM-IV-TR had a further requirement that the individual’s response involved intense fear, helplessness, or horror, but that has been dropped in the DSM-5 due to there being little empirical support for its usefulness. Criterion B asks that the individual be experiencing at least nine symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal. Criterion C notes that symptoms must begin by the third day after the event and go for one month (after which PTSD may be considered). The other two criteria require that the disturbance be causing clinically significant distress in most important areas of functioning and that the disturbance not be attributable to the physiological effects of a substance or another medical condition (Australian Centre for Posttraumatic Mental Health, 2013a and 2013b).

The DSM-5 description of ASD

A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:

• Directly experiencing the traumatic event(s).
• Witnessing, in person, the traumatic event(s) as they occurred to others.
• Learning that the traumatic events(s) occurred to a close family member of close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
• Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse). This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related.

B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:

Intrusion symptoms:

• Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
• Recurrent distressing dreams in which the content and/or affect of the dream is related to the event(s). In children, there may be frightening dreams without recognisable content.
• Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings. In children, trauma-specific re-enactment may occur in play.
• Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolise or resemble an aspect of the traumatic event(s).
• Negative mood.
• Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

Dissociative symptoms:

• An altered sense of the reality of one’s surroundings or oneself, such as seeing oneself from another’s perspective, being in a daze, or having the sense of time slowing.
• Inability to remember an important aspect of the traumatic event(s), typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs.
• Avoidance symptoms.
• Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
• Efforts to avoid external reminders – meaning people, places, conversations, activities, objects, or situations – that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
• Arousal symptoms.
• Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep.
• Irritable behaviour and angry outbursts with little or no provocation, typically expressed as verbal or physical aggression toward people or objects.
• Hypervigilance.
• Problems with concentration.
• Exaggerated startle response.

C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure. Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance, such as medication or alcohol, or another medical condition (for example: mild traumatic brain injury), and is not better explained by brief psychotic disorder (Australian Centre for Posttraumatic Mental Health, 2013b).

Posttraumatic stress disorder

In the DSM-IV-TR, PTSD was considered to be one of the anxiety disorders. In the DSM-5, it has been moved to a new category: “Trauma- and Stressor-Related Disorders” (Friedman, Resick, Bryant, Strain, Horowitz, & Spiegel, 2011). The DSM-IV-TR named six sets of criteria to be met if PTSD were to be diagnosed. In the DSM-5, these are expanded to eight. There are four symptom clusters in the DSM-5 (compared to the three of the DSM-IV-TR) because the single category of “avoidance and numbing” has been separated into two clusters in the DSM-5.

What can constitute a traumatic event is defined in the first criterion (A). As with ASD, the old DSM-IV-TR requirement (A2) that the individual’s response involve intense fear, helplessness, or horror has been deleted from the DSM-5 because there is little empirical support for its usefulness. Criterion B lists the intrusion symptoms, of which one or more must be present. Criterion C outlines avoidance symptoms (one must be present), and Criterion D delineates seven numbing symptoms (two or more are required). Arousal symptoms are covered in Criterion E (two symptoms needed), and duration requirements in Criterion F. Criterion G notes the requirement for clinically significant distress or impairment, while the criterion H stipulates that the symptoms not be attributable to the effects of a substance or another medical condition. There are two sections of PTSD symptoms in the DSM-5: the first for adults and children over six years of age, and the second for pre-school children. The requirements for diagnosis of PTSD are listed below.

Tip: Click here for a post exploring the differences between the DSM-IV-TR and DSM-5.

The DSM-5 description of PTSD

Adolescents and children older than six:

A. Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:

• Directly experiencing the traumatic event(s).
• Witnessing, in person, the traumatic event(s) as it/they occurred to others.
• Learning that the traumatic event(s) occurred to a close family member or close friend. In such cases, the event(s) must have been violent or accidental.
• Experiencing repeated or extreme exposure to aversive details of the traumatic event(s), such as first responders who collect human remains or police officers who are repeatedly exposed to details of child abuse. This does not apply to exposure through electronic media, television, movies or pictures unless the exposure is work-related.

B. Presence of one or more of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

• Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
• Recurrent distressing dreams in which the content and/or affect of the dream is related to the event(s). In children, there may be frightening dreams without recognisable content.
• Dissociative reactions (for example, flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring (such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings. In children, trauma-specific re-enactment may occur in play.
• Intense or prolonged psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event(s).
• Marked physiological reactions upon exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s), occurred, as evidenced by avoidance or efforts to avoid one or both of the following:

• Distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
• External reminders – that is, the people, places, conversations, activities, objects, or situations – that arouse distressing memories, thoughts, or feelings about or closely associated with, the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following:

• Inability to remember an important aspect of the traumatic event(s), typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs.
• Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (for example: “I am bad”, “No one can be trusted”, “The world is completely dangerous”, or “My whole nervous system is permanently ruined”).
• Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame him/herself or others.
• Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
• Markedly diminished interest or participation in significant activities.
• Feelings of detachment or estrangement from others.
• Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following:

• Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects
• Reckless or self-destructive behavior
• Hypervigilance.
• Exaggerated startle response.
• Problems with concentration.
• Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not attributed to the direct physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

The clinician is instructed to specify if the presentation is:

• With dissociative symptoms: The individual’s symptoms meet the criteria for PTSD and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:
• Depersonalisation: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of one’s mental processes or body (e.g., feeling as though one were in a dream, feeling a sense of unreality of self or body or of time moving slowly).
  Derealisation: Persistent or recurrent experiences of unreality of surroundings (e.g., world around the individual is experienced as unreal, dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (for example blackouts or behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

The clinician is also to specify if there is delayed expression, in which case the full diagnostic criteria are not met until at least six months after the event (although the onset and expression of some symptoms may be immediate) (Australian Centre for Posttraumatic Mental Health, 2013b).

Preschool children:

A. In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

• Directly experiencing the event(s).
• Witnessing, in person, the event(s) as they occurred to others, especially primary caregivers. Note that “witnessing” does not include events that are seen only in electronic media, television, movies, or pictures.
• Learning that the traumatic event(s) occurred to a parent or caregiving figure.

B. Presence of one or more intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

• Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). It should be noted that spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play re-enactment.
• Recurrent distressing dreams in which the content and/or affect of the dream is related to the traumatic event(s). Note that it may not be possible to ascertain that the frightening content is related to the traumatic event.
• Dissociative reactions in which the child feels or acts as if the traumatic event(s) were recurring. Such reactions may occur on a continuum with the most extreme expression being a complete loss of awareness of present surroundings. Such trauma-specific re-enactment may occur in play.
• Intense or prolonged psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event(s).
• Marked physiological reactions to reminders of the traumatic event(s).

C. One or more of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic even(s) or negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the event(s):

Persistent avoidance of stimuli:

• Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event.
• Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event.
• Negative alterations in cognitions.
• Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion).
• Markedly diminished interest or participation in significant activities, including construction of play.
• Socially withdrawn behaviour.
• Persistent reduction in expression of positive emotions.

D. Alterations in arousal and reactivity associated with the traumatic event, beginning or worsening after the traumatic event occurred, as evidenced by two or more of the following:

• Irritable behaviour and angry outbursts with little or no provocation, typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums).
• Hypervigilance.
• Exaggerated startle response.
• Problems with concentration.
• Sleep disturbance (for example, difficulty falling or staying asleep or restless sleep).

E. Duration of the disturbance (Criteria B, C, and D is more than one month).

F. The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behaviour.

G. The disturbance is not attributable to the physiological effects of a substance (for example, medication or alcohol) or another medical condition.

The clinician is to specify whether the presentation is:

• With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:
• Depersonalisation: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (for example, feeling as though one were in a dream, feeling a sense of unreality of self or body or of time moving slowly).
• Derealisation: Persistent or recurrent experiences of unreality of surroundings (for example, the world around the individual is experienced as unreal, dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, or behaviour during alcohol intoxication), or another medical condition (e.g., complex partial seizures).

The clinician is also to specify if there is delayed expression, in which case the full diagnostic criteria are not met until at least six months after the event (although the onset and expression of some symptoms may be immediate) (Australian Centre for Posttraumatic Mental Health, 2013b).

Complex PTSD and DESNOS

Some individuals, particularly those whose PTEs have been of an interpersonal, prolonged, and repeated nature (such as with sexual abuse, torture, or imprisonment), occasionally present with a constellation of symptoms in addition to the core symptoms of PTSD. These features may include:

• Impaired emotional control
• Self-destructive and impulsive behaviour
• Impaired relationships with others;
• Hostility
• Social withdrawal
• Feeling constantly threatened
• Dissociation
• Somatic complaints
• Feelings of ineffectiveness
• Shame
• Despair or hopelessness
• Feeling permanently damaged
• Loss of prior beliefs and assumptions about their safety and the trustworthiness of others
• Chronic self-harm and/or suicidal ideation

People displaying these features are often spoken of as having Complex PTSD or Disorders of Extreme Stress Not Otherwise Specified (DESNOS) (Herman, 1992; Zlotnick, Zakriski, Shea, & Costello, 1996).

Source: www.mentalhealthacademy.com.au

References

• Australian Centre for Posttraumatic Mental Health. (2013a). Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder. ACPMH, Melbourne, Victoria.
• Australian Centre for Posttraumatic Mental Health. (2013b). Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder: Guidelines Summary. ACPMH, Melbourne, Victoria.
• Bryant, R.A., O’Donnell, M.L., Creamer, M., McFarlane, A.C., Clark, C.R., & Silove, D. (2010). The psychiatric sequelae of traumatic injury. American Journal of Psychiatry, Vol 16, No 3, 312-320. DOI: 10.1176/appi.ajp.2009.09050617.
• Creamer, M., Burgess, P., & McFarlane, A.C. (2001). Post-traumatic stress disorder: findings from the Australian National Survey of Mental Health and Well-being. Psychological Medicine, Vol 31, 1237-1247.
• Friedman, M.J., Resick, P.A., Bryant, R.A., Strain, J., Horowitz, M., & Spiegel, D. (2011). Classification of trauma and stressor-related disorders in DSM-5. Depression and Anxiety, Vol 28, No 9, 737-749. DOI: 10.1002/da.20845.
• Harper, D. (2015). Trauma. Online Etymology Dictionary. Retrieved on 30 July, 2015, from: hyperlink.
• Purdie, N., Dudgeon, P., & Walker, R. (Eds.). (2010). Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. Canberra: Australian Government Department of Health and Ageing.